I, (PRINCIPAL), do hereby name and designate (PRIMARY AGENT) as my primary funeral planning agent, or if he/she is unwilling or incapable (ALTERNATE AGENT) as my alternate funeral planning agent, who shall have the sole responsibility and authority to make any and all arrangements and decisions regarding my funeral preparation and planning, burial or disposition of my remains, including cremation, upon my death, pursuant to the provisions of § 5-33.2-24. By signing this document, the aforementioned agent(s) agree to ensure payment for all outstanding expenses related to my funeral. The agent further certifies that if I am a non-relative to the agent, then I am the only non-relative for whom the agent is serving as a funeral planning agent. This document shall revoke and shall make null and void any and all previous designations of a funeral planning agent.
Witness: _____________________________________ | Principal: _____________________________________ |
_________ | |
(Name and address of Witness) | Name and address of Principal: |
_____________________________________ | _____________________________________ |
Dated: _____________________________________ | Dated: |
Primary Agent: _____________________________________ | Alternate Agent: _____________________________________ |
Name and Address of Primary | Name and Address of Alternate |
Agent | Agent |
_________ | |
Dated: _______________________________________ | Dated: _______________________________________ |
State of _____________________________________ | County of _____________________________________ |
Subscribed and sworn to before me this _________ day of _____________________________________ | |
_________ | |
_____________________________________ (Notary Public) |
R.I. Gen. Laws § 5-33.3-4